Healthcare Provider Details

I. General information

NPI: 1043284029
Provider Name (Legal Business Name): LEONEL A URDANETA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 W ROYAL PALM RD
PHOENIX AZ
85021-4916
US

IV. Provider business mailing address

6817 N 22ND PL
PHOENIX AZ
85016-1146
US

V. Phone/Fax

Practice location:
  • Phone: 602-808-2800
  • Fax:
Mailing address:
  • Phone: 505-697-8999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1531
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number53538
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: